Effect of Mirror Therapy on Dexterity and Hand Grasp in Children Aged 9-14 Years with Hemiplegic Cerebral Palsy.

Objectives
Mirror therapy using visual feedback is one of the non-invasive methods along with other commonly used rehabilitation treatments for neurological patients which therapeutic effects on the affected upper limb of children with hemiplegic cerebral palsy have also been studied. We aimed to examine the effect of mirror therapy on improving the dexterity and grasp of children with hemiplegic cerebral palsy.


Materials & Methods
In this single-blind clinical trial, 30 children with hemiplegic cerebral palsy in rehabilitation centers and special schools of Tabriz, northwest of Iran were randomly divided into two intervention and control groups in 2017. The children of the intervention group were under mirror therapy for 6 weeks. Occupational therapy exercise was done routinely for both groups. The grasp with dynamometer and the dexterity with box and block was measured. Data were analyzed using independent t-test and paired t-test.


Results
The mean scores of the two groups in dexterity were significantly different after the intervention (P=0.008). However, there was no significant difference between the two groups in grasp.


Conclusion
Mirror therapy in hemiplegic children is useful in improving the dexterity but not in improving of the grasp.


Introduction
Pediatric cerebral palsy (CP) involves a group of progressive sensory and motor impairment as well as postural dysfunction caused by non-progressive damage to the immature brain (1). The prevalence of CP in the world is reported 2-3/1000 and in Iran, it is reported as 2.06/1000 live births (2,3). One of the types of CP is spastic hemiplegia, known as half-body paralysis and the prevalence is about 35.1% of all children with CP (4). Upper limb function impairment is a common and disability consequence of problems in reaching, pointing, taking, releasing and manipulating objects (5). The ability to reach and grasp things is one of the basic tasks in activities of daily living (6).
Among non-invasive approaches, mirror therapy is a relatively new approach that focuses on visual stimulation and the movement of limbs without damage. The reflection of the healthy limb movement in the mirror is thought the affected limb is moving naturally (7). In this method, the patient places his hands on the two sides of the mirror, so that the healthy hand is in front of the mirror and the affected hand behind the mirror.
Thus, the patient understands the reflection of his healthy hand in the mirror as his affected hand (8).
Mirror therapy, as a simple, inexpensive and, most importantly, a referral-based program, may improve the function of the limbs (9). This method does not require much activity and energy from the therapist, and the patient can even continue treatment at home after learning how to proceed (10).
Studies on the effect of mirror therapy on a variety of patients have shown that mirror therapy can improve the motor function of the upper extremity along with other rehabilitation programs. The effect of these studies on children in hemiplegia also shows that grasp and dexterity are significantly increased during a regular and continuous training program (11,12). Moreover, improving the range of motion and increasing the score of the Quest as well as Box and Block tests following is a mirror therapy (13,14). In another study, mirror therapeutic exercises showed a significant difference in grasp and PDMS scale compared to the control group (15).
In summary, there is little evidence of the effect of the mirror therapy in children with hemiplegic CP, and more studies have been done in a pilot or case study and are less than 10 yr old, therefore, we decided to investigate in clinical trial, the effect of mirror therapy on grasp and dexterity of the upper limb in children with hemiplegic CP aged 9-14 yr old.

Materials & Methods
In this single-blind clinical trial, 30 children aged In this research, written and informed consent was obtained from each participating child. The mean and standard deviation of dexterity were calculated in both groups before and after the intervention.

The present study was approved by the Ethics
There was no significant difference between the two groups in the dexterity before intervention, but there was a significant difference after the mirror therapy (Table 2). The mean and standard deviation of grasp were calculated in both groups before and after the intervention.
There was no significant difference between the two groups in the grasp before and after intervention (Table 3).   (23)(24).
In the present study, all children were given counseling and training to do better exercises.
Following these tutorials and recommendations in the process of improving children is very